Pre-Consultation Form

Pre-Consultation Form
Item ID
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Street Address
City
State
Postal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are you currently married to the other party?
Date of Marriage

MonthDayYear
Date
Is your marriage a covenant marriage?
Children

Name and age of children common to both parties.
Name (child 1)
Age (child 1)
Name (child 2)
Age (child 2)
Name (child 3)
Age (child 3)
Please provide names and ages of any additional children common to both parties.
Employment
Are you employed?
If yes, name of employer:
Occupation:
Gross Monthly Income:
Do either of you own any businesses?
If yes, nature of business:
Assets
Do you have joint bank accounts with your spouse?
Do you own a home?
Do you own additional real estate?
Do you have investment or retirement accounts?
Status
Have you already filed for divorce?
If yes, date of filing:

MonthDayYear
Date
Have you retained an attorney?
If yes, name of attorney:
Do you have a pre-marital or post-marital agreement?
Have you had marriage or family counseling?
If yes, name of therapist:
Personal Information

The following questions may be sensitive and personal. Your responses are private and will not be shared with the other party.
Are you presently in therapy or counseling?
If yes, name of therapist:
Has there been physical confrontation between you and your spouse?
If yes, information:
Is an Order of Protection or Restraining Order in place?
If yes, information:
Do you have any concerns about your safety with the other person?
If yes, information:
Has Child Protective Services ever been involved with the family regarding allegations of abuse or neglect of the children?
If yes, CPS or Juvenile Court case number:
If necessary, how would you prefer to be contacted about the information shared here?
How did you find out about us?
Name of therapist:
Do you want to mediate? Why or why not?
Should be Empty:

Pre-Consultation Form

Children

Employment

Assets

Status

Personal Information